1
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Martin KR, Gamell C, Tai TY, Bonelli R, Hansen J, Tatoulis J, Alhamdoosh M, Wilson N, Wicks I. Whole blood transcriptomics reveals granulocyte colony-stimulating factor as a mediator of cardiopulmonary bypass-induced systemic inflammatory response syndrome. Clin Transl Immunology 2024; 13:e1490. [PMID: 38375330 PMCID: PMC10875393 DOI: 10.1002/cti2.1490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 12/20/2023] [Accepted: 01/23/2024] [Indexed: 02/21/2024] Open
Abstract
Objectives Systemic inflammatory response syndrome (SIRS) is a frequent complication of cardiopulmonary bypass (CPB). SIRS is associated with significant morbidity and mortality, but its pathogenesis remains incompletely understood, and as a result, biomarkers are lacking and treatment remains expectant and supportive. This study aimed to understand the pathophysiological mechanisms driving SIRS induced by CPB and identify novel therapeutic targets that might reduce systemic inflammation and improve patient outcomes. Methods Twenty-one patients undergoing cardiac surgery and CPB were recruited, and blood was sampled before, during and after surgery. SIRS was defined using the American College of Chest Physicians/Society of Critical Care Medicine criteria. We performed immune cell profiling and whole blood transcriptomics and measured individual mediators in plasma/serum to characterise SIRS induced by CPB. Results Nineteen patients fulfilled criteria for SIRS, with a mean duration of 2.7 days. Neutrophil numbers rose rapidly with CPB and remained elevated for at least 48 h afterwards. Transcriptional signatures associated with neutrophil activation and degranulation were enriched during CPB. We identified a network of cytokines governing these transcriptional changes, including granulocyte colony-stimulating factor (G-CSF), a regulator of neutrophil production and function. Conclusions We identified neutrophils and G-CSF as major regulators of CPB-induced systemic inflammation. Short-term targeting of G-CSF could provide a novel therapeutic strategy to limit neutrophil-mediated inflammation and tissue damage in SIRS induced by CPB.
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Affiliation(s)
- Katherine R Martin
- WEHIParkvilleVICAustralia
- Department of Medical BiologyUniversity of MelbourneParkvilleVICAustralia
| | | | - Tsin Yee Tai
- WEHIParkvilleVICAustralia
- CSL Innovation, Bio21 InstituteParkvilleVICAustralia
| | - Roberto Bonelli
- WEHIParkvilleVICAustralia
- Department of Medical BiologyUniversity of MelbourneParkvilleVICAustralia
- CSL Innovation, Bio21 InstituteParkvilleVICAustralia
| | | | - James Tatoulis
- Cardiothoracic SurgeryRoyal Melbourne HospitalParkvilleVICAustralia
- Department of SurgeryUniversity of MelbourneParkvilleVICAustralia
| | | | | | - Ian Wicks
- WEHIParkvilleVICAustralia
- Department of Medical BiologyUniversity of MelbourneParkvilleVICAustralia
- Department of RheumatologyRoyal Melbourne HospitalParkvilleVICAustralia
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2
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Abbasciano RG, Tomassini S, Roman MA, Rizzello A, Pathak S, Ramzi J, Lucarelli C, Layton G, Butt A, Lai F, Kumar T, Wozniak MJ, Murphy GJ. Effects of interventions targeting the systemic inflammatory response to cardiac surgery on clinical outcomes in adults. Cochrane Database Syst Rev 2023; 10:CD013584. [PMID: 37873947 PMCID: PMC10594589 DOI: 10.1002/14651858.cd013584.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
BACKGROUND Organ injury is a common and severe complication of cardiac surgery that contributes to the majority of deaths. There are no effective treatment or prevention strategies. It has been suggested that innate immune system activation may have a causal role in organ injury. A wide range of organ protection interventions targeting the innate immune response have been evaluated in randomised controlled trials (RCTs) in adult cardiac surgery patients, with inconsistent results in terms of effectiveness. OBJECTIVES The aim of the review was to summarise the results of RCTs of organ protection interventions targeting the innate immune response in adult cardiac surgery. The review considered whether the interventions had a treatment effect on inflammation, important clinical outcomes, or both. SEARCH METHODS CENTRAL, MEDLINE, Embase, conference proceedings and two trial registers were searched on October 2022 together with reference checking to identify additional studies. SELECTION CRITERIA RCTs comparing organ protection interventions targeting the innate immune response versus placebo or no treatment in adult patients undergoing cardiac surgery where the treatment effect on innate immune activation and on clinical outcomes of interest were reported. DATA COLLECTION AND ANALYSIS Searches, study selection, quality assessment, and data extractions were performed independently by pairs of authors. The primary inflammation outcomes were peak IL-6 and IL-8 concentrations in blood post-surgery. The primary clinical outcome was in-hospital or 30-day mortality. Treatment effects were expressed as risk ratios (RR) and standardised mean difference (SMD) with 95% confidence intervals (CI). Meta-analyses were performed using random effects models, and heterogeneity was assessed using I2. MAIN RESULTS A total of 40,255 participants from 328 RCTs were included in the synthesis. The effects of treatments on IL-6 (SMD -0.77, 95% CI -0.97 to -0.58, I2 = 92%) and IL-8 (SMD -0.92, 95% CI -1.20 to -0.65, I2 = 91%) were unclear due to heterogeneity. Heterogeneity for inflammation outcomes persisted across multiple sensitivity and moderator analyses. The pooled treatment effect for in-hospital or 30-day mortality was RR 0.78, 95% CI 0.68 to 0.91, I2 = 0%, suggesting a significant clinical benefit. There was little or no treatment effect on mortality when analyses were restricted to studies at low risk of bias. Post hoc analyses failed to demonstrate consistent treatment effects on inflammation and clinical outcomes. Levels of certainty for pooled treatment effects on the primary outcomes were very low. AUTHORS' CONCLUSIONS A systematic review of RCTs of organ protection interventions targeting innate immune system activation did not resolve uncertainty as to the effectiveness of these treatments, or the role of innate immunity in organ injury following cardiac surgery.
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Affiliation(s)
| | | | - Marius A Roman
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Angelica Rizzello
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Suraj Pathak
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Joussi Ramzi
- Leicester Medical School, University of Leicester, Leicester, UK
| | - Carla Lucarelli
- Department of Cardiac Surgery, University of Verona, Verona, Italy
| | - Georgia Layton
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Ayesha Butt
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Florence Lai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Tracy Kumar
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Marcin J Wozniak
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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3
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Scott Eldredge R, Russell KW. Pediatric surgical interventions on ECMO. Semin Pediatr Surg 2023; 32:151330. [PMID: 37931540 DOI: 10.1016/j.sempedsurg.2023.151330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
Extra Corporeal Membrane Oxygenation (ECMO) has historically been reserved for refractory pulmonary and cardiac support in children and adult. Operative intervention on ECMO was traditionally contraindicated due to hemorrhagic complications exacerbated by critical illness and anticoagulation needs. With advancements in ECMO circuitry and anticoagulation strategies operative procedures during ECMO have become feasible with minimal hemorrhagic risks. Here we review anticoagulation and operative intervention considerations in the pediatric population during ECMO cannulation. Pediatric surgical interventions currently described in the literature while on ECMO support include thoracotomy/thoracoscopy, tracheostomy, laparotomy, and injury related procedures i.e. wound debridement. A patient should not be precluded from a surgical intervention while on ECMO, if the surgery is indicated.
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Affiliation(s)
- R Scott Eldredge
- Department of Surgery, Mayo Clinic, Phoenix, AZ, United States; Department of Pediatric Surgery, Phoenix Children's, Phoenix, AZ, United States
| | - Katie W Russell
- Department of Surgery, Division of Pediatric Surgery, University of Utah, Salt Lake City, UT, United States.
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4
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Sang L, Guo X, Zhao Y, Shi J, Niu Z, Wu Z, Hou S, Fan H, Lv Q. Protective Effect of Nebulized Heparin in the Animal Models of Smoke Inhalation Injury: A Meta-analysis and Systematic Review of Experimental Studies. J Burn Care Res 2023; 44:42-52. [PMID: 36269755 DOI: 10.1093/jbcr/irac156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Indexed: 01/14/2023]
Abstract
The pathophysiological mechanism of abnormal coagulation can result from smoke inhalation injury (SII). Heparin nebulization is a common treatment for lung disorders. This study aimed to use meta-analysis in animal models to examine the effectiveness of atomized heparin on SII. For our online searches, we used the Cochrane Central Register of Controlled Trials, PubMed, Web of Science, Chinese National Knowledge Infrastructure, Chinese BioMedical Literature Database, and Wanfang Database up to January 2022. Data for SII were retrieved and compared to control animals. The studies' findings were determined by combining standardized mean difference (SMD) analysis with 95% confidence intervals (CIs). The findings showed that as compared to the control group, the heparin-treated group had a lower death rate (relative risk 0.42; 95% CI 0.22, 0.80; p < .05). The meta-analysis demonstrated favorable changes in lung physiology, including PaO2/FiO2 (SMD 1.04; 95% CI 0.65, 1.44; p < .001), lung wet-to-dry weight ratio (SMD -1.83; 95% CI -2.47, -1.18; p < .001), and pulmonary shunt Qs/Qt (SMD -0.69; 95% CI -1.29, -0.08; p < .05) after heparin nebulization for lung injury. The present data indicated that pulmonary artery mean pressure in the heparin therapy group was significantly lowered after 24 and 48 hours of therapy, suggesting that the cardiovascular system could recover following heparin treatment. As a result, heparin nebulization appeared to be more effective against SII and improved cardiopulmonary function compared to the control group. Graphical Abstract.
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Affiliation(s)
- Lu Sang
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.,Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin, China
| | - Xiaoqin Guo
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.,Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin, China
| | - Yuchen Zhao
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.,Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin, China
| | - Jie Shi
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.,Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin, China
| | - Zhifang Niu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.,Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin, China
| | - Zhenlong Wu
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.,Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin, China
| | - Shike Hou
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.,Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin, China
| | - Haojun Fan
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.,Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin, China
| | - Qi Lv
- Institute of Disaster and Emergency Medicine, Tianjin University, Tianjin, China.,Tianjin Key Laboratory of Disaster Medicine Technology, Tianjin, China
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5
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Rajsic S, Breitkopf R, Jadzic D, Popovic Krneta M, Tauber H, Treml B. Anticoagulation Strategies during Extracorporeal Membrane Oxygenation: A Narrative Review. J Clin Med 2022; 11:jcm11175147. [PMID: 36079084 PMCID: PMC9457503 DOI: 10.3390/jcm11175147] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Revised: 08/24/2022] [Accepted: 08/29/2022] [Indexed: 11/30/2022] Open
Abstract
The development of extracorporeal life support technology has added a new dimension to the care of critically ill patients who fail conventional treatment options. Extracorporeal membrane oxygenation (ECMO)—specialized temporary life support for patients with severe cardiac or pulmonary failure—plays a role in bridging the time for organ recovery, transplant, or permanent assistance. The overall patient outcome is dependent on the underlying disease, comorbidities, patient reaction to critical illness, and potential adverse events during ECMO. Moreover, the contact of the blood with the large artificial surface of an extracorporeal system circuit triggers complex inflammatory and coagulation responses. These processes may further lead to endothelial injury and disrupted microcirculation with consequent end-organ dysfunction and the development of adverse events like thromboembolism. Therefore, systemic anticoagulation is considered crucial to alleviate the risk of thrombosis and failure of ECMO circuit components. The gold standard and most used anticoagulant during extracorporeal life support is unfractionated heparin, with all its benefits and disadvantages. However, therapeutic anticoagulation of a critically ill patient carries the risk of clinically relevant bleeding with the potential for permanent injury or death. Similarly, thrombotic events may occur. Therefore, different anticoagulation strategies are employed, while the monitoring and the balance of procoagulant and anticoagulatory factors is of immense importance. This narrative review summarizes the most recent considerations on anticoagulation during ECMO support, with a special focus on anticoagulation monitoring and future directions.
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Affiliation(s)
- Sasa Rajsic
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Robert Breitkopf
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Dragana Jadzic
- Anaesthesia and Intensive Care Department, Pain Therapy Service, Cagliari University, 09042 Cagliari, Italy
| | | | - Helmuth Tauber
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Benedikt Treml
- Department of Anaesthesiology and Intensive Care Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
- Correspondence: ; Tel.: +43-50504-82231
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6
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Canjuga D, Hansen C, Halbrügge F, Hann L, Weiß S, Schlensak C, Wendel HP, Avci-Adali M. Improving hemocompatibility of artificial lungs by click conjugation of glycoengineered endothelial cells onto blood-contacting surfaces. BIOMATERIALS ADVANCES 2022; 137:212824. [PMID: 35929239 DOI: 10.1016/j.bioadv.2022.212824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/01/2022] [Accepted: 04/20/2022] [Indexed: 06/15/2023]
Abstract
Artificial lungs, also known as oxygenators, allow adequate oxygenation of the blood in patients with severe respiratory failure and enable patient survival. However, the insufficient hemocompatibility of the current of artificial lungs hampers their long-term use. Therefore, in this study, a novel strategy was developed to efficiently endothelialize blood-contacting surfaces to improve their hemocompatibility. Hollow fiber membranes (HFMs) were functionalized with dibenzylcyclooctyne (DBCO), and endothelial cells were glycoengineered for covalent conjugation to DBCO by a copper-free click reaction. Metabolic glycoengineering using azidoacetylmannosamine-tetraacylated (Ac4ManNAz) resulted in highly efficient functionalization of endothelial cells with azide (N3) molecules on the cell surface without negative impact on cell viability. After 48 h, significantly improved endothelialization was detected on the HFM surfaces functionalized with DBCO compared to unmodified HFMs. Endothelial cells were responsive to inflammatory stimulus and expressed adhesion-promoting molecules (E-selectin, VCAM-1, and ICAM-1). Furthermore, the hemocompatibility of HFMs was analyzed by dynamic incubation with fresh human blood. DBCO-coated and uncoated HFMs showed a comparable hemocompatibility, but the endothelialization of HFMs significantly reduced the activation of blood coagulation and platelets. Interestingly, the incubation of endothelialized HFMs with human blood further reduced the expression of E-selectin and VCAM-1 in endothelial cells. In this study, a highly efficient, cell-compatible method for endothelialization of artificial lungs was established. This click chemistry-based method can be also applied for the endothelialization of other artificial surfaces for tissue engineering and regenerative medicine applications.
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Affiliation(s)
- Denis Canjuga
- University Hospital Tuebingen, Department of Thoracic and Cardiovascular Surgery, Calwerstraße 7/1, 72076 Tuebingen, Germany
| | - Caroline Hansen
- University Hospital Tuebingen, Department of Thoracic and Cardiovascular Surgery, Calwerstraße 7/1, 72076 Tuebingen, Germany
| | - Franziska Halbrügge
- University Hospital Tuebingen, Department of Thoracic and Cardiovascular Surgery, Calwerstraße 7/1, 72076 Tuebingen, Germany
| | - Ludmilla Hann
- University Hospital Tuebingen, Department of Thoracic and Cardiovascular Surgery, Calwerstraße 7/1, 72076 Tuebingen, Germany
| | - Sarina Weiß
- University Hospital Tuebingen, Department of Thoracic and Cardiovascular Surgery, Calwerstraße 7/1, 72076 Tuebingen, Germany
| | - Christian Schlensak
- University Hospital Tuebingen, Department of Thoracic and Cardiovascular Surgery, Calwerstraße 7/1, 72076 Tuebingen, Germany
| | - Hans-Peter Wendel
- University Hospital Tuebingen, Department of Thoracic and Cardiovascular Surgery, Calwerstraße 7/1, 72076 Tuebingen, Germany
| | - Meltem Avci-Adali
- University Hospital Tuebingen, Department of Thoracic and Cardiovascular Surgery, Calwerstraße 7/1, 72076 Tuebingen, Germany.
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7
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Hatami S, Hefler J, Freed DH. Inflammation and Oxidative Stress in the Context of Extracorporeal Cardiac and Pulmonary Support. Front Immunol 2022; 13:831930. [PMID: 35309362 PMCID: PMC8931031 DOI: 10.3389/fimmu.2022.831930] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/08/2022] [Indexed: 12/12/2022] Open
Abstract
Extracorporeal circulation (ECC) systems, including cardiopulmonary bypass, and extracorporeal membrane oxygenation have been an irreplaceable part of the cardiothoracic surgeries, and treatment of critically ill patients with respiratory and/or cardiac failure for more than half a century. During the recent decades, the concept of extracorporeal circulation has been extended to isolated machine perfusion of the donor organ including thoracic organs (ex-situ organ perfusion, ESOP) as a method for dynamic, semi-physiologic preservation, and potential improvement of the donor organs. The extracorporeal life support systems (ECLS) have been lifesaving and facilitating complex cardiothoracic surgeries, and the ESOP technology has the potential to increase the number of the transplantable donor organs, and to improve the outcomes of transplantation. However, these artificial circulation systems in general have been associated with activation of the inflammatory and oxidative stress responses in patients and/or in the exposed tissues and organs. The activation of these responses can negatively affect patient outcomes in ECLS, and may as well jeopardize the reliability of the organ viability assessment, and the outcomes of thoracic organ preservation and transplantation in ESOP. Both ECLS and ESOP consist of artificial circuit materials and components, which play a key role in the induction of these responses. However, while ECLS can lead to systemic inflammatory and oxidative stress responses negatively affecting various organs/systems of the body, in ESOP, the absence of the organs that play an important role in oxidant scavenging/antioxidative replenishment of the body, such as liver, may make the perfused organ more susceptible to inflammation and oxidative stress during extracorporeal circulation. In the present manuscript, we will review the activation of the inflammatory and oxidative stress responses during ECLP and ESOP, mechanisms involved, clinical implications, and the interventions for attenuating these responses in ECC.
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Affiliation(s)
- Sanaz Hatami
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Canadian National Transplant Research Program, Edmonton, AB, Canada
| | - Joshua Hefler
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Darren H. Freed
- Department of Surgery, University of Alberta, Edmonton, AB, Canada
- Canadian National Transplant Research Program, Edmonton, AB, Canada
- Department of Biomedical Engineering, University of Alberta, Edmonton, AB, Canada
- Alberta Transplant Institute, Edmonton, AB, Canada
- Department of Physiology, University of Alberta, Edmonton, AB, Canada
- *Correspondence: Darren H. Freed,
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8
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Zhang M, Pauls JP, Bartnikowski N, Haymet AB, Chan CHH, Suen JY, Schneider B, Ki KK, Whittaker AK, Dargusch MS, Fraser JF. Anti-thrombogenic Surface Coatings for Extracorporeal Membrane Oxygenation: A Narrative Review. ACS Biomater Sci Eng 2021; 7:4402-4419. [PMID: 34436868 DOI: 10.1021/acsbiomaterials.1c00758] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is used in critical care to manage patients with severe respiratory and cardiac failure. ECMO brings blood from a critically ill patient into contact with a non-endothelialized circuit which can cause clotting and bleeding simultaneously in this population. Continuous systemic anticoagulation is needed during ECMO. The membrane oxygenator, which is a critical component of the extracorporeal circuit, is prone to significant thrombus formation due to its large surface area and areas of low, turbulent, and stagnant flow. Various surface coatings, including but not limited to heparin, albumin, poly(ethylene glycol), phosphorylcholine, and poly(2-methoxyethyl acrylate), have been developed to reduce thrombus formation during ECMO. The present work provides an up-to-date overview of anti-thrombogenic surface coatings for ECMO, including both commercial coatings and those under development. The focus is placed on the coatings being developed for oxygenators. Overall, zwitterionic polymer coatings, nitric oxide (NO)-releasing coatings, and lubricant-infused coatings have attracted more attention than other coatings and showed some improvement in in vitro and in vivo anti-thrombogenic effects. However, most studies lacked standard hemocompatibility assessment and comparison studies with current clinically used coatings, either heparin coatings or nonheparin coatings. Moreover, this review identifies that further investigation on the thrombo-resistance, stability and durability of coatings under rated flow conditions and the effects of coatings on the function of oxygenators (pressure drop and gas transfer) are needed. Therefore, extensive further development is required before these new coatings can be used in the clinic.
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Affiliation(s)
- Meili Zhang
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia.,School of Mechanical and Mining Engineering, The University of Queensland, Brisbane, Queensland 4072,Australia
| | - Jo P Pauls
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia.,School of Engineering and Built Environment, Griffith University, Southport, Queensland 4222, Australia
| | - Nicole Bartnikowski
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia.,School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, Queensland 4000, Australia
| | - Andrew B Haymet
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia
| | - Chris H H Chan
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia.,School of Engineering and Built Environment, Griffith University, Southport, Queensland 4222, Australia
| | - Jacky Y Suen
- Scientific and Translational Research Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland 4072, Australia
| | - Bailey Schneider
- Scientific and Translational Research Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia
| | - Katrina K Ki
- Scientific and Translational Research Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia
| | - Andrew K Whittaker
- Australian Institute for Bioengineering and Nanotechnology and ARC Center of Excellence in Convergent Bio-Nano Science and Technology, The University of Queensland, Brisbane, Queensland 4072, Australia
| | - Matthew S Dargusch
- School of Mechanical and Mining Engineering, The University of Queensland, Brisbane, Queensland 4072,Australia
| | - John F Fraser
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia.,Scientific and Translational Research Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland 4032, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland 4072, Australia.,School of Medicine, Griffith University, Southport, Queensland 4222, Australia
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9
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Sniderman J, Monagle P, Annich GM, MacLaren G. Hematologic concerns in extracorporeal membrane oxygenation. Res Pract Thromb Haemost 2020; 4:455-468. [PMID: 32548547 PMCID: PMC7292669 DOI: 10.1002/rth2.12346] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/27/2020] [Accepted: 03/31/2020] [Indexed: 12/16/2022] Open
Abstract
This ISTH "State of the Art" review aims to critically evaluate the hematologic considerations and complications in extracorporeal membrane oxygenation (ECMO). ECMO is experiencing a rapid increase in clinical use, but many questions remain unanswered. The existing literature does not address or explicitly state many pertinent details that may influence hematologic complications and, ultimately, patient outcomes. This review aims to broadly introduce modern ECMO practices, circuit designs, circuit materials, hematologic complications, transfusion-related considerations, age- and size-related differences, and considerations for choosing outcome measures. Relevant studies from the 2019 ISTH Congress in Melbourne, which further advanced our understanding of these processes, will also be highlighted.
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Affiliation(s)
| | - Paul Monagle
- Department of PaediatricsDepartment of HaematologyUniversity of MelbourneThe Royal Children's HospitalHaematology Research Murdoch Children’s Research InstituteMelbourneVic.Australia
| | - Gail M. Annich
- Department of Critical Care MedicineThe Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
| | - Graeme MacLaren
- Paediatric ICURoyal Children’s HospitalMelbourneVic.Australia
- Department of PaediatricsUniversity of MelbourneParkvilleVic.Australia
- Cardiothoracic ICUNational University Health SystemSingapore CitySingapore
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10
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Ontaneda A, Annich GM. Novel Surfaces in Extracorporeal Membrane Oxygenation Circuits. Front Med (Lausanne) 2018; 5:321. [PMID: 30525038 PMCID: PMC6256321 DOI: 10.3389/fmed.2018.00321] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 10/30/2018] [Indexed: 01/01/2023] Open
Abstract
The balance between systemic anticoagulation and clotting is challenging. In normal hemostasis, the endothelium regulates the balance between anticoagulant and prothrombotic systems. It becomes particularly more challenging to maintain this physiologic hemostasis when we are faced with extracorporeal life support therapies, where blood is continuously in contact with a foreign extracorporeal circuit surface predisposing a prothrombotic state. The blood-surface interaction during extracorporeal life support therapies requires the use of systemic anticoagulation to decrease the risk of clotting. Unfractionated heparin is the most common anticoagulant agent widely used in this setting. New trends include the use of direct thrombin inhibitor agents for systemic anticoagulation; and surface modifications that aim to overcome the blood-biomaterial surface interaction by modifying the hydrophilicity or hydrophobicity of the polymer surface; and coating the circuit with substances that will mimic the endothelium or anti-thrombotic agents. To improve hemocompatibility in an extracorporeal circuit, replication of the anti-thrombotic and anti-inflammatory properties of the endothelium is ideal. Surface modifications can be classified into three major groups: biomimetic surfaces (heparin, nitric oxide, and direct thrombin inhibitors); biopassive surfaces [phosphorylcholine, albumin, and poly- 2-methoxyethylacrylate]; and endothelialization of blood contacting surface. The focus of this paper will be to review both present and future novel surface modifications that can obviate the need for systemic anticoagulation during extracorporeal life support therapies.
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Affiliation(s)
- Andrea Ontaneda
- Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Gail M Annich
- Department of Critical Care Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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11
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Toikkanen V, Rinne T, Laurikka J, Porkkala H, Tarkka M, Mennander A. Pulmonary vascular resistance index during coronary artery bypass surgery with aprotinin. Scandinavian Journal of Clinical and Laboratory Investigation 2017; 77:315-320. [PMID: 28460544 DOI: 10.1080/00365513.2017.1318446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Low pulmonary vascular resistance index (PVRI) reflects favorable redundant pulmonary circulation following coronary artery bypass grafting with cardiopulmonary bypass surgery (CPB). This randomized study investigated whether aprotinin given in different modalities impacts PVRI after coronary artery bypass grafting. A total of 40 patients undergoing coronary artery bypass grafting were randomized to four groups according to aprotinin dose: (1) high dose, (2) early low dose, (3) late low dose, and (4) without aprotinin. Oxygenation index, pulmonary shunt, alveolar-arterial oxygen gradient and PVRI were determined. PVRI was calculated as the transpulmonary pressure gradient divided by cardiac index multiplied by 80. The results showed that PVRI remained relative low in all patients provided aprotinin regardless of treatment dosage; PVRI increased at 4 h after restarting ventilation after CPB in patients without aprotinin as compared with aprotinin (266 ± 137, 266 ± 115, 244 ± 86 vs. 386 ± 121, dynes-s-cm-5, respectively, p = .047). Elevated postoperative PVRI was predictive for patients without aprotinin (AUC 0.668; SE 0.40; p < .0001; CI 0.590-0.746). There were no statistical differences in oxygenation index, pulmonary shunt or alveolar-arterial oxygen gradient between the groups. In conclusion, aprotinin maintains a low PVRI in elective patients with healthy lungs during CPB. We suggest that aprotinin maintains pulmonary arterial endothelial integrity.
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Affiliation(s)
- Vesa Toikkanen
- a Department of Cardiothoracic Surgery , Heart Center, Tampere University Hospital and University of Tampere , Tampere , Finland
| | - Timo Rinne
- b Division of Cardiac Anesthesia , Heart Center, Tampere University Hospital , Tampere , Finland
| | - Jari Laurikka
- a Department of Cardiothoracic Surgery , Heart Center, Tampere University Hospital and University of Tampere , Tampere , Finland
| | - Helena Porkkala
- b Division of Cardiac Anesthesia , Heart Center, Tampere University Hospital , Tampere , Finland
| | - Matti Tarkka
- a Department of Cardiothoracic Surgery , Heart Center, Tampere University Hospital and University of Tampere , Tampere , Finland
| | - Ari Mennander
- a Department of Cardiothoracic Surgery , Heart Center, Tampere University Hospital and University of Tampere , Tampere , Finland
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Melchior RW, Sutton SW, Harris W, Dalton HJ. Evolution of membrane oxygenator technology for utilization during pediatric cardiopulmonary bypass. Pediatric Health Med Ther 2016; 7:45-56. [PMID: 29388637 PMCID: PMC5683297 DOI: 10.2147/phmt.s35070] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The development of the membrane oxygenator for pediatric cardiopulmonary bypass has been an incorporation of ideology and technological advancements with contributions by many investigators throughout the past two centuries. With the pursuit of this technological achievement, the ability to care for mankind in the areas of cardiac surgery has been made possible. Heart disease can affect anyone within the general population, but one such segment that it can affect from inception includes children. Currently, congenital heart defects are the most common birth defects nationally and worldwide. A large meta-analysis study from 1930 to 2010 was conducted in review of published medical literature totaling 114 papers with a study population of 24,091,867 live births, and divulged a staggering incidence of congenital heart disease involving 164,396 subjects with diverse cardiac illnesses. The prevalence of these diseases increased from 0.6 per 1,000 live births from 1930-1934 to 9.1 per 1,000 live births after 1995. These data reveal an emphasis on a growing public health issue regarding congenital heart disease. This discovery displays a need for heightened awareness in the scientific and medical industrial community to accelerate investigative research on emerging cardiovascular devices in an effort to confront congenital anomalies. One such device that has evolved over the past several decades is the pediatric membrane oxygenator. The pediatric membrane oxygenator, in conjunction with the heart lung machine, assists in the repair of most congenital cardiac defects. Numerous children born with congenital heart disease with or without congestive heart failure have experienced improved clinical outcomes in quality of life, survival, and mortality as a result of the inclusion of this technology during their cardiac surgical procedure. The purpose of this review is to report a summary of the published medical and scientific literature related to development of the pediatric membrane oxygenator from its conceptual evolutionary stages to artificially supporting whole body perfusion in the modern pediatric cardiac surgical setting.
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Affiliation(s)
- Richard W Melchior
- Department of Perfusion Services, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - William Harris
- Department of Perfusion Services, Ochsner Clinic Foundation, New Orleans, LA
| | - Heidi J Dalton
- Alaskan Native Tribal Health Consortium, Anchorage, AK
- Department of Child Health, University of Arizona-College of Medicine, Phoenix, AZ, USA
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Kenne E, Nickel KF, Long AT, Fuchs TA, Stavrou EX, Stahl FR, Renné T. Factor XII: a novel target for safe prevention of thrombosis and inflammation. J Intern Med 2015; 278:571-85. [PMID: 26373901 DOI: 10.1111/joim.12430] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Plasma protein factor XII (FXII) activates the procoagulant and proinflammatory contact system that drives both the kallikrein-kinin system and the intrinsic pathway of coagulation. When zymogen FXII comes into contact with negatively charged surfaces, it auto-activates to the serine proteaseactivated FXII (FXIIa). Recently, various in vivo activators of FXII have been identified including heparin, misfolded protein aggregates, polyphosphate and nucleic acids. Murine models have established a central role of FXII in arterial and venous thrombosis. Despite its central function in thrombosis, deficiency in FXII does not impair haemostasis in animals and humans. In a preclinical cardiopulmonary bypass system in large animals, the FXIIa-blocking antibody 3F7 prevented thrombosis; however, in contrast to traditional anticoagulants, bleeding was not increased. In addition to its function in thrombosis, FXIIa initiates formation of the inflammatory mediator bradykinin. This mediator increases vascular leak, causes vasodilation, and induces chemotaxis with implications for septic, anaphylactic and allergic disease states. Therefore, targeting FXIIa appears to be a promising strategy for thromboprotection without associated bleeding risks but with anti-inflammatory properties.
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Affiliation(s)
- E Kenne
- Division of Clinical Chemistry, Department of Molecular Medicine and Surgery, Karolinska Institutet and University Hospital, Stockholm, Sweden.,Center of Molecular Medicine, Karolinska Institutet and University Hospital, Stockholm, Sweden
| | - K F Nickel
- Division of Clinical Chemistry, Department of Molecular Medicine and Surgery, Karolinska Institutet and University Hospital, Stockholm, Sweden.,Center of Molecular Medicine, Karolinska Institutet and University Hospital, Stockholm, Sweden.,Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A T Long
- Department of Medicine, Hematology and Oncology Division, Case Western Reserve University and Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - T A Fuchs
- Division of Clinical Chemistry, Department of Molecular Medicine and Surgery, Karolinska Institutet and University Hospital, Stockholm, Sweden.,Center of Molecular Medicine, Karolinska Institutet and University Hospital, Stockholm, Sweden.,Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - E X Stavrou
- Department of Medicine, Hematology and Oncology Division, Case Western Reserve University and Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - F R Stahl
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - T Renné
- Division of Clinical Chemistry, Department of Molecular Medicine and Surgery, Karolinska Institutet and University Hospital, Stockholm, Sweden.,Center of Molecular Medicine, Karolinska Institutet and University Hospital, Stockholm, Sweden.,Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Murphy DA, Hockings LE, Andrews RK, Aubron C, Gardiner EE, Pellegrino VA, Davis AK. Extracorporeal membrane oxygenation-hemostatic complications. Transfus Med Rev 2014; 29:90-101. [PMID: 25595476 DOI: 10.1016/j.tmrv.2014.12.001] [Citation(s) in RCA: 252] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 10/19/2014] [Accepted: 12/03/2014] [Indexed: 12/17/2022]
Abstract
The use of extracorporeal membrane oxygenation (ECMO) support for cardiac and respiratory failure has increased in recent years. Improvements in ECMO oxygenator and pump technologies have aided this increase in utilization. Additionally, reports of successful outcomes in supporting patients with respiratory failure during the 2009 H1N1 pandemic and reports of ECMO during cardiopulmonary resuscitation have led to increased uptake of ECMO. Patients requiring ECMO are a heterogenous group of critically ill patients with cardiac and respiratory failure. Bleeding and thrombotic complications remain a leading cause of morbidity and mortality in patients on ECMO. In this review, we describe the mechanisms and management of hemostatic, thrombotic and hemolytic complications during ECMO support.
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Affiliation(s)
- Deirdre A Murphy
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Australia; Department of Epidemiology and Preventative Medicine, School of Public Health, Monash University, Melbourne, Australia.
| | - Lisen E Hockings
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Australia; Department of Epidemiology and Preventative Medicine, School of Public Health, Monash University, Melbourne, Australia
| | - Robert K Andrews
- Australian Centre for Blood Diseases, Monash University, Melbourne, Australia
| | - Cecile Aubron
- ANZIC Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Vincent A Pellegrino
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Australia; Department of Epidemiology and Preventative Medicine, School of Public Health, Monash University, Melbourne, Australia
| | - Amanda K Davis
- Department of Haematology, Alfred Hospital Melbourne, Australia
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Kenne E, Renné T. Factor XII: a drug target for safe interference with thrombosis and inflammation. Drug Discov Today 2014; 19:1459-64. [PMID: 24993156 DOI: 10.1016/j.drudis.2014.06.024] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 06/23/2014] [Indexed: 02/02/2023]
Abstract
Data from experimental animal models revealed an essential role for factor XII (FXII) in thrombotic occlusive diseases. In contrast to other blood coagulation factors, deficiency in the protease is not associated with abnormal bleeding from injury sites (hemostasis) in patients or in animals. Cumulatively, these findings suggest that FXII could be targeted as a new method of anticoagulation that is devoid of bleeding risks. An FXIIa-neutralizing antibody, 3F7, has been developed that inhibited thrombosis in an extracorporeal membrane oxygenation (ECMO) system as efficiently as heparin. However, in sharp contrast to heparin, 3F7 treatment was not associated with an increase in therapy-associated hemorrhage. In this review, we summarize current knowledge of FXII physiology and pharmacology.
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Affiliation(s)
- Ellinor Kenne
- Department of Molecular Medicine and Surgery, Karolinska Institutet and University Hospital, SE-171 76 Stockholm, Sweden; Center of Molecular Medicine, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Thomas Renné
- Department of Molecular Medicine and Surgery, Karolinska Institutet and University Hospital, SE-171 76 Stockholm, Sweden; Center of Molecular Medicine, Karolinska University Hospital, SE-171 76 Stockholm, Sweden; Institute of Clinical Chemistry and Laboratory Medicien, University Medical Center Hamburg-Eppendorf, D-20246 Hamburg, Germany.
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Larsson M, Rayzman V, Nolte MW, Nickel KF, Bjorkqvist J, Jamsa A, Hardy MP, Fries M, Schmidbauer S, Hedenqvist P, Broome M, Pragst I, Dickneite G, Wilson MJ, Nash AD, Panousis C, Renne T. A Factor XIIa Inhibitory Antibody Provides Thromboprotection in Extracorporeal Circulation Without Increasing Bleeding Risk. Sci Transl Med 2014; 6:222ra17. [DOI: 10.1126/scitranslmed.3006804] [Citation(s) in RCA: 231] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Belway D, Rubens FD. Currently available biomaterials for use in cardiopulmonary bypass. Expert Rev Med Devices 2014; 3:345-55. [PMID: 16681456 DOI: 10.1586/17434440.3.3.345] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cardiopulmonary bypass (CPB) represents one of the most important technical innovations in healthcare history, yet the systemic responses to CPB remain a fundamentally unresolved problem. Study of the blood-biomaterial interaction and development of biocompatible materials is intimately related to efforts to optimize patient outcome following CPB. This article reviews the design innovations in biomaterial surfaces that have been introduced into clinical practice in an attempt to ameliorate the detrimental consequences of CPB, contrasting the actual clinical improvements and patient benefits achieved against those predicted on the basis of theory and in vitro testing. Some discussion of the underlying mechanisms of action as presently understood is provided and the current limitations of biomaterial-dependent strategies to improve outcome following CPB are addressed.
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Affiliation(s)
- Dean Belway
- University of Ottawa Heart Institute, Department of Cardiovascular Perfusion, 40 Ruskin St., Ottawa, Ontario K1Y 4W7, Canada
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Toikkanen V, Rinne T, Huhtala H, Laurikka J, Porkkala H, Tarkka M, Mennander A. Cardiopulmonary bypass decreases pulmonary vascular resistance index after coronary artery bypass surgery. Scandinavian Journal of Clinical and Laboratory Investigation 2013; 74:37-43. [DOI: 10.3109/00365513.2013.856032] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Marcoux JE, Mycyk TR. Are any biocompatible coatings capable of attenuating the deleterious effects of cardiopulmonary bypass? Perfusion 2013; 28:433-9. [DOI: 10.1177/0267659113483802] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Biocompatible circuits (BCC) are intended to decrease the activation of blood to the artificial cardiopulmonary bypass (CPB) surface. Typically, the coatings are made of various inert substances or molecules physiologically similar to endothelium. Thromboelastography (TEG) graphically represents clot formation, strength of clotting and fibrinolysis. TEG analysis was undertaken to determine if coagulation could be preserved by the BCC. Methods: Five different BCC were studied in clinical applications. These five coated circuits were then compared to an identical circuit where only the oxygenator was coated. A pre- and post-bypass TEG was done for comparison. Six well-studied parameters of TEG analysis were compared: R time, Angle, K, Maximum Amplitude (MA), LY30% and Clot Index (CI). Postoperative bleeding and transfusion requirements were compared to TEG results for comparison. Results: All postoperative TEG results were significantly different from preoperative parameters except LY30%. No BCC circuit was able to prevent the significant disruption of the observed TEG coagulation parameters R, K, angle, MA and CI. Of note, the postoperative TEG parameters resulting from the Control and Trillium™ groups – which had the same type of oxygenator – were practically identical. The oxygenator, which represents the largest surface area in the CPB circuit, is the single most important factor influencing coagulation. Conclusion: While not harmful, BCC are ineffective in preserving TEG coagulation parameters post CPB. Clinical findings support laboratory TEG results in that there were no differences in bleeding or transfusion requirements between groups.
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Affiliation(s)
- JE Marcoux
- Royal University Hospital, Saskatoon, Canada
| | - TR Mycyk
- Royal University Hospital, Saskatoon, Canada
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Marcoux J, Sohn N, McNair E, Rosin M, Smith G, Lim H, Mycyk T, Meng Q. Outcomes comparison of 5 coated cardiopulmonary bypass circuits versus an uncoated control group of patients undergoing cardiac surgery. Perfusion 2009; 24:307-15. [DOI: 10.1177/0267659109352114] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Attenuated inflammatory response and decreased platelet activation have been claimed repeatedly when biocompatible circuits are used for cardiopulmonary bypass. We evaluated five Health Canada approved biocompatible circuit coatings (BCC) against an un-coated control group to determine their effectiveness in improving post-operative outcomes. Patients were assigned to the Control group or one of the 5 coated circuit groups: 40 Control; 33 Trillium; 32 Phisio; 34 Bioline; 33 X; and 11 GBS. Measured outcomes included: ventilator time; ICU time; post-operative chest tube drainage and transfusion volume; high sensitivity C-reactive protein (hsCRP); tau protein; and pre- and 72-hour post-operative anti-saccadic eye movement test comparisons. Results: 183 patients were enlisted into the study. One arm of the study (GBS) was abandoned after 11 patients on account of inconsistent pressure excursions within the oxygenator and the excessive consumption of platelets necessitating transfusion. Patients in the X-coated group had significantly longer ventilator and intensive care unit (ICU) time compared to the three remaining coated circuit study groups. Though not significant, patients in the X group also demonstrated the highest post-operative chest tube losses, the most platelet transfusions, the highest tau protein levels and the lowest post-operative anti-saccadic eye movement test (ASEMT) results compared to the three remaining coated groups. The patients in the Trillium, Bioline and Phisio groups showed an improvement in ventilator and ICU time relative to the Control group. The diabetic patients in the Trillium, Bioline and Phisio groups showed an improvement in bleeding relative to the diabetic patients in the Control group. Conclusion: We compared all 5 coated circuits approved for clinical use in Canada against an uncoated control circuit. Three of the 5 coated circuits (Trillium, Phisio and Bioline BCC) were found to improve ventilator and ICU time compared to Control. Further studies are indicated to validate these results and their impact upon approval criteria, purchasing choices and safe clinical practice, especially as applied to higher risk diabetic patients.
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Affiliation(s)
- J. Marcoux
- Department of Clinical Perfusion, Cardiovascular Surgery and Clinical Chemistry, Royal University Hospital, Saskatoon, Saskatchewan, Canada,
| | - N. Sohn
- Department of Clinical Perfusion, Cardiovascular Surgery and Clinical Chemistry, Royal University Hospital, Saskatoon, Saskatchewan, Canada
| | - E. McNair
- Department of Clinical Perfusion, Cardiovascular Surgery and Clinical Chemistry, Royal University Hospital, Saskatoon, Saskatchewan, Canada
| | - M. Rosin
- Department of Clinical Perfusion, Cardiovascular Surgery and Clinical Chemistry, Royal University Hospital, Saskatoon, Saskatchewan, Canada
| | - G. Smith
- Department of Clinical Perfusion, Cardiovascular Surgery and Clinical Chemistry, Royal University Hospital, Saskatoon, Saskatchewan, Canada
| | - H. Lim
- Department of Clinical Perfusion, Cardiovascular Surgery and Clinical Chemistry, Royal University Hospital, Saskatoon, Saskatchewan, Canada
| | - T. Mycyk
- Department of Clinical Perfusion, Cardiovascular Surgery and Clinical Chemistry, Royal University Hospital, Saskatoon, Saskatchewan, Canada
| | - Q. Meng
- Department of Clinical Perfusion, Cardiovascular Surgery and Clinical Chemistry, Royal University Hospital, Saskatoon, Saskatchewan, Canada
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